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Presented by Peter Illei, M.D. and prepared by Todd Sheridan, M.D.
Case 1: This a 42-year-old female patient was evaluated for uterine fibroids and on the ultrasound exam a right adrenal mass was noted.
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1. Question
Week 256: Case 1
This a 42-year-old female patient was evaluated for uterine fibroids and on the ultrasound exam a right adrenal mass was noted. Subsequent lab tests showed elevated serum testosterone and serum cortisol within normal limits. In addition, the patient had a 1-year history of hirsutism, acne, and hypertension. MRI was performed that showed a right adrenal tumor measuring 4.0 cm. The patient underwent a right adrenalectomy. At gross exam the adrenal weighed 32.5 grams. On cut sections a 4×3.5×3 cm well-circumscribed nodule was identified that was surrounded by a fibrous capsule and by normal appearing narrow rim of adrenal cortex. No necrosis was grossly noted./images/2.7.06.PIcase1a.jpg
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Answer: Adrenal cortical adenoma with oncocytic features
Histology: none provided
Discussion: The tumor is encapsulated and is confined within the adrenal cortex. The tumor cells have abundant eosinophilic-granular (oncocytic) cytoplasm and variably sized round to oval nuclei with prominent nucleoli. Scattered large atypical cells with markedly enlarged nuclei are also noted. No mitosis, vascular invasion, capsular invasion or necrosis is present. Immunostains demonstrate that the tumor cells are melan-A and inhibin positive and S-100 negative. This staining pattern is consistent with an adrenal cortical neoplasm.
Clinically, the tumor was testosterone producing and resulted in hirsutism and acne. Androgen-secreting adrenal cortical tumors are rare and when present usually are malignant and the patients present with symptoms of androgen excess. On the other hand, adrenal oncocytomas are typically hormonally inactive and histologically similar to oncocytomas of other sites and have a benign course. On macroscopic exam this tumor had benign features (32.5 g, 4.0 cm, no necrosis, encapsulated and confined to the adrenal cortex). On microscopic exam the tumor had a solid growth pattern, oncocytic features with less than 25% clear cells, cytologic atypia, but no mitosis, necrosis, vascular or capsular invasion. These features indicate a benign course in some classifications (Van Slooten et al.) and indeterminate (Weiss et al. and Hough et al.) in others.
Reference(s):
– WHO Classification of Tumors. Pathology and genetics of Endocrine Organs. pp. 139-146. IARC Press 2004.Incorrect
Answer: Adrenal cortical adenoma with oncocytic features
Histology: none provided
Discussion: The tumor is encapsulated and is confined within the adrenal cortex. The tumor cells have abundant eosinophilic-granular (oncocytic) cytoplasm and variably sized round to oval nuclei with prominent nucleoli. Scattered large atypical cells with markedly enlarged nuclei are also noted. No mitosis, vascular invasion, capsular invasion or necrosis is present. Immunostains demonstrate that the tumor cells are melan-A and inhibin positive and S-100 negative. This staining pattern is consistent with an adrenal cortical neoplasm.
Clinically, the tumor was testosterone producing and resulted in hirsutism and acne. Androgen-secreting adrenal cortical tumors are rare and when present usually are malignant and the patients present with symptoms of androgen excess. On the other hand, adrenal oncocytomas are typically hormonally inactive and histologically similar to oncocytomas of other sites and have a benign course. On macroscopic exam this tumor had benign features (32.5 g, 4.0 cm, no necrosis, encapsulated and confined to the adrenal cortex). On microscopic exam the tumor had a solid growth pattern, oncocytic features with less than 25% clear cells, cytologic atypia, but no mitosis, necrosis, vascular or capsular invasion. These features indicate a benign course in some classifications (Van Slooten et al.) and indeterminate (Weiss et al. and Hough et al.) in others.
Reference(s):
– WHO Classification of Tumors. Pathology and genetics of Endocrine Organs. pp. 139-146. IARC Press 2004.
